— 心理社會完整性 · MEDIUM · MCQ —
一位 25 歲廣泛性焦慮症病史的病人到診，主訴心悸與強烈瀕死感。護理師首要介入措施為何？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic reporting heart palpitations and a feeling of impending doom. Which intervention is the highest priority for the nurse?
- AEncourage the client to talk about their feelings鼓勵個案談論其感受
- BAssess the client for physiological causes of symptoms✓ 正解評估個案症狀的生理原因
- CInstruct the client to practice deep breathing exercises指導個案練習深呼吸運動
- DAdminister an as-needed benzodiazepine給予處方之按需使用之苯二氮平類藥物
— Explanation · 中文詳解 —
面對焦慮症病人的生理主訴，護理師的首要任務是排除任何可能導致心悸的急性生理問題（如心律不整、甲狀腺亢進或過量咖啡因）。在確認生理指標穩定前，不可假設症狀純為焦慮發作。穩定身體狀況（安全）是心理護理的前提。
The highest priority is to assess for physiological causes of symptoms, such as arrhythmias or hyperthyroidism, before assuming the presentation is purely anxiety-related. Ruling out life-threatening medical conditions ensures patient safety and is essential prior to implementing psychological interventions or administering anxiolytics.
✦ 台美臨床差異
美國護理師常需在 triage 階段區分 panic attack 與心肌梗塞；台灣則常由急診醫師先行診斷，護理師負責監測。